Method to evaluate patients for thoracic outlet syndrome

ABSTRACT

Methods to obtain three-dimensional models and images for diagnosis of Thoracic Outlet Syndrome are described.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.14/629,310, titled METHOD TO EVALUATE PATIENTS FOR THORACIC OUTLETSYNDROME, filed Feb. 23, 2015, which is a continuation of U.S. patentapplication Ser. No. 11/595,741, titled METHOD TO EVALUATE PATIENTS FORTHORACIC OUTLET SYNDROME, filed Nov. 9, 2006, which claims benefit ofU.S. Provisional Application No. 60/840,887, titled METHOD TO EVALUATEPATIENTS FOR THORACIC OUTLET SYNDROME, filed Aug. 28, 2006. Each of theforegoing applications is hereby incorporated by reference herein in itsentirety.

TECHNICAL FIELD

The invention relates to methods of evaluating and diagnosing ThoracicOutlet Syndrome (TOS) using magnetic resonance imaging and magneticresonance angiography.

BACKGROUND ART

The brachial plexus is a large cluster of nerves that passes from thespinal cord through the neck and the upper chest to the shoulder andarm. To reach the arm, the brachial plexus must pass through at leastthree anatomic tunnels. The main blood supply to and from the arm isprovided by the subclavian artery and the subclavian vein, respectively.These major blood vessels pass through the same anatomic tunnels as thebrachial plexus. Thoracic Outlet Syndrome (TOS) is a complex of signsand symptoms that results from narrowing of these tunnels andcompression of one or more of these vital structures. TOS can be dividedinto three primary types:

-   -   Neurogenic Thoracic Outlet Syndrome: Neurogenic TOS is a        compressive and entrapment neuropathy in which one or more of        these tunnels becomes narrow, creating mechanical compression on        the brachial plexus and/or altering its blood supply. This        compression and altered blood flow result in pain, abnormal        sensation, weakness, and eventual loss of muscle function in the        affected areas.    -   Arterial Thoracic Outlet Syndrome: Arterial TOS results from        mechanical compression of the subclavian or axillary artery,        which causes arterial stenosis, post-stenotic aneurysm        formation, and intramural thrombus formation. These changes        result in decreased blood flow to the arm and/or embolism of        thrombus to distal vessels, with pain, weakness, coldness and        loss of pulse in the affected arm.    -   Venous Thoracic Outlet Syndrome: Venous TOS results from        mechanical compression of the subclavian or axillary vein, which        causes occlusive or non-occlusive thrombosis of the vein, damage        to the lining of the vein, and eventual stricture formation that        persists despite resolution of the extrinsic mechanical        compression. These changes result in swelling, cyanosis, pain        and altered function of the affected arm.

The causative mechanisms for all three types of primary TOS are nearlyidentical, and compression of one vital structure is often accompaniedby compression of the other vital structures in varying degrees.Therefore, each primary type of TOS described above frequently includesa component of one or both of the other two types of TOS.

Thoracic Outlet Syndrome occurs when two conditions are met:

-   -   The patient has anatomic predispositions or anomalies. These can        include abnormal muscles or fibrous bands, exaggeration or        distortion of the usual shapes of the chest and shoulder girdle        bony structures, anomalous courses of the nerves that make up        the brachial plexus, or anomalous arteries or veins that pass        through the thoracic outlet.    -   The patient has a superimposed traumatic event or repetitive        overuse syndrome that:        -   Alters the soft tissues or bony structures that make up the            anatomic tunnels, or        -   That causes direct injury to the brachial plexus, arteries,            veins or soft tissues and bony structures that make up the            anatomic tunnels, or        -   That alters the posture and position of the neck and            shoulder girdle, leading to narrowing of the anatomic            tunnels through which the brachial plexus, arteries and            veins pass.

Neurogenic TOS is a compressive and entrapment neuropathy that has beenclinically recognized for over one hundred years. Physicians frequentlyfind these patients' cases complex and challenging. Patients often havea slowly-evolving course, experiencing symptoms intermittently early inthe course of the disease and often only being symptomatic with the armsand neck in certain positions. As the disease progresses, the patientsexperience symptoms continuously, regardless of the position of theirarms and neck. Patients often experience sensory changes early in thecourse of the disease, followed by vague muscle aching as the diseaseprogresses. Eventually, patients experience muscle weakness, which inthe late stages becomes evident as muscle atrophy and wasting, if thecorrect diagnosis is not made and definitive treatment is notundertaken. Unfortunately, when the disease progresses to this extent,muscle weakness and atrophy are unlikely to improve, even withdefinitive treatment.

Arterial TOS is frequently associated with an anomalous extra rib in thelower cervical spine, and was the first clinical form of TOS to berecognized, beginning with a case described in England in 1821, followedby a surgically proven case in 1861. It often has a dramatic clinicalpresentation due to either decreased blood flow to the affected arm orto the sudden development of blood clots embolizing to the distalvessels of the arm, causing gangrene. In this setting, the diagnosis isreadily made. However, early diagnosis is critical to prevent theoccurrence of these potentially serious complications.

Venous TOS frequently occurs in patients with an occupation requiringrepetitive and/or strenuous use of their upper extremities, and is knownby several other names, including effort thrombosis and Paget-Schroettersyndrome. It often has a dramatic clinical presentation due to swellingof the affected arm, decreased blood flow or loss of function. Inaddition, these patients are at risk of pulmonary embolism and pulmonaryhypertension, either of which may be fatal. In this setting, thediagnosis is readily made. However, early diagnosis is critical toprevent the occurrence of potentially serious thromboembolic events, andto prevent permanent damage to the compressed vein, which predisposesthe patient to repeated episodes of thrombosis formation and symptomseven after the mechanical compression of the vein has been treated.

Clinical, electrophysiologic and imaging tests have been developed overthe past century, but none have been widely accepted as a gold standardfor the diagnosis of TOS. Clinical tests utilize various positions ofthe patient's neck and arms while the pulse is palpated at the wrist.These tests have been shown to have a high number of false positive andfalse negative results. Electrophysiological tests are used to rule outthe presence of other compressive and entrapment neuropathies of theupper extremity, but cannot confirm or rule out the diagnosis of TOS.Imaging tests have been used to evaluate the anatomy and pathology inpatients with TOS. These tests have changed as the technology hasevolved to allow more refined evaluation of anatomy and pathology inpatients with TOS.

Since the 1960's, contrast angiography or venography has been performedto evaluate the arteries or veins of the arms, respectively, with thepatient's arms placed in various provocative positions. This methodduplicates the clinical tests in which the patient's pulse is palpatedas their arms are moved into symptomatic positions. Angiography andvenography are limited to evaluation of the compressed arteries andveins, but do not evaluate the abnormal anatomic tunnels that arecausing this compression. Since the 1980's, CT scanning has beenperformed to evaluate the bony structures that border the thoracicoutlet, or the arteries and veins of the arms, with the patient's armsplaced in various provocative positions. CT scanning can also beperformed with the patient's arms by their sides, allowing evaluation ofthe changes in the bony anatomic tunnels that occur with arm motion, andthe resulting effects on the accompanying arteries or veins. CT scanningis limited in its evaluation of soft tissues, with inadequatedifferentiation of muscles and nerves in the thoracic outlet. Since theearly 1990s, MRI scanning has been performed for the evaluation of softtissue structures in the thoracic outlet, including the nerves of thebrachial plexus, the arteries and veins of the arm, or the muscles thatborder the anatomic tunnels through which these vital structures pass toreach the arm. Like CT scanning, MRI scanning can be performed with thepatient's arms placed in various provocative positions.

Each of these imaging tests has focused on one component of TOS,evaluating the bony structures, soft tissues, arteries, veins, ornerves. To date, there has been no single process that evaluatescomprehensively the nerves, arteries and veins that pass through thethoracic outlet, the muscles and bony structures that form the anatomictunnels of the thoracic outlet, the changes in the thoracic outlet thatoccur on arm movement, and the resulting effects of these changes on thebrachial plexus, arteries and veins as they pass through these tunnels.The invention technique accomplishes these goals.

DISCLOSURE OF THE INVENTION

The invention provides a comprehensive process that permits accurateevaluation of patients for the presence or absence of Thoracic OutletSyndrome (TOS). The invention employs magnetic resonance imagingtechniques, magnetic resonance angiography and, optionally, magneticresonance venography. Images are obtained as the basis for 3-dimensionalmodels which are reviewed in addition to the original images by aradiologist according to a checklist of items with respect to each modeland image.

Thus, in one aspect, the invention is directed to

A method to evaluate a human subject for the presence or absence ofthoracic outlet syndrome (TOS) which method comprises:

a) obtaining a first set of magnetic resonance imaging (MRI) slices ineach of three planes, in the absence of contrast agent,

b) with the subject in a supine position with both arms in a neutralposition by the side of the body,

using a surface coil placed to cover the upper chest and neck, and thesupraclavicular fossa region on the affected side(s),

wherein a gradient echo T1, a spin-echo T1, or fast spin echoT2-weighted sequence comprises sagittal slices that cover the scalenetriangle, costoclavicular space, and retropectoralis space on theaffected side(s); and

wherein a gradient echo T1, spin-echo T1, or fast spin echo T2-weightedsequence comprises axial slices that cover the mid and lower cervicalspine and lower neck, and the brachial plexus, supraclavicular space,superior mediastinum and lung apex on the affected side(s); and

wherein a Short Tau Inversion Recovery (STIR) sequence comprises coronalslices that cover the volume of the brachial plexus on the affectedside(s);

b) obtaining a second set of MRI slices in one or more planes,

with the subject in a supine position with both arms placed in abductionand external rotation,

using a surface coil placed to cover the upper chest and neck, and thesupraclavicular fossa region on the affected side(s),

wherein the sequence that comprises the sagittal slices are obtained asin subparagraph a), in the absence of contrast agent, followed by

an optional sequence that comprises the axial slices, obtained as insubparagraph a), in the absence of contrast agent, followed by

intravenously administering a contrast agent, and

obtaining a contrast-enhanced magnetic resonance angiogram (MRA) duringthe arterial enhancement phase following said administering whichcomprises coronal slices prescribed to cover the subclavian and axillaryarteries on the affected side(s); after which,

optionally obtaining a magnetic resonance venogram (MRV) performedduring the arteriovenous equilibrium or venous enhancement phasefollowing said administering which comprises coronal slices prescribedto cover the subclavian, axillary and brachiocephalic veins on theaffected side(s);

c) composing the slices from the STIR sequence into a composite volume,and editing the composite volume to create a three-dimensional model ofthe brachial plexus on the affected side(s);

d) composing the slices from the MRA into a composite volume, andediting the composite volume to create a three-dimensional model of thearteries on the affected side(s); and

e) composing the slices from the MRV, if performed, into a compositevolume, and editing the composite volume to create a three-dimensionalmodel of the veins on the affected side(s); and

f) evaluating the first and second sets of MRI slices of a) and b) andthe three-dimensional models of c) and d) and optionally e) according toa checklist,

whereby the presence or absence of TOS in the subject is evaluated.

The evaluation data may also be stored on electronic media for futurereference. Accordingly, in another aspect, the invention is directed toan electronic recording medium comprising evaluation data obtainedaccording to the checklist described herein.

MODES FOR CARRYING OUT THE INVENTION

In general, the method of the invention involves obtaining a series ofimages, manipulating these images, and drawing conclusions from themaccording to a checklist of locations and evaluations. The radiologistwill typically view and evaluate between 700 and 1,000 images displayedon a work station, for a patient who has both sides examined. A detaileddescription of the images to be obtained is as follows. While gadoliniumis used as the contrast agent below, alternative similarly respondingcontrast agents, including but not limited to para-CEST agents may beused.

The patient is placed in supine position in the MRI scanner, with botharms in neutral position, by the side of the body. A neurovascular coilor similar coil that covers the upper chest, neck and supraclavicularfossa region on each side is used. The following sequences are thenperformed:

-   -   3D localizer sequence, using gradient recalled technique.    -   Coronal STIR (Short Tau Inversion Recovery) sequence, prescribed        to cover the volume of the brachial plexus on the affected        side(s).    -   Sagittal gradient echo T1, spin-echo T1 or fast spin echo        T2-weighted sequence, prescribed to cover the scalene triangle,        costoclavicular space and retropectoralis space on the affected        side(s).    -   Axial gradient echo T1, spin-echo T1 or fast spin echo        T2-weighted sequence, prescribed to cover the mid and lower        cervical spine and lower neck, and the brachial plexus,        supraclavicular space, superior mediastinum and lung apex on the        affected side(s).

The patient is then removed from the scanner, placed back in the scannerwith both arms in abduction and external rotation, and a coil is placedto cover the patient's upper chest, neck and supraclavicular fossaregion on each side. An intravenous line is placed in the patient'santecubital or hand vein at this time, if one has not already beenplaced earlier. This intravenous line is connected to a standard MRIpower injector. The injector is pre-loaded with one syringe of normalsaline (optional), and one syringe containing gadolinium contrastmaterial, or a mixture of gadolinium contrast material and normalsaline. The following sequences are then performed:

-   -   3D localizer sequence, using gradient recalled technique.    -   Sagittal gradient echo T1, spin echo T1 or fast spin echo        T2-weighted sequence, prescribed to cover the scalene triangle,        costoclavicular space and retropectoralis space on the affected        side(s).    -   Axial gradient echo T1, spin echo T1 or fast spin echo        T2-weighted sequence, prescribed to cover the mid and lower        cervical spine and lower neck, and the brachial plexus,        supraclavicular space, superior mediastinum and lung apex on the        affected side(s).    -   Time of flight angiogram, oriented in the coronal plane,        prescribed to cover the subclavian, axillary and brachial artery        on the affected side(s), performed during the arterial        enhancement phase following injection of gadolinium contrast        material via the previously placed intravenous line.    -   Time of flight venogram, oriented in the coronal plane,        prescribed to cover the subclavian, axillary and brachial artery        and vein on the affected side(s), performed during the venous or        equilibrium enhancement phase following injection of gadolinium        contrast material via the previously placed intravenous line        (this sequence is optional).

After the above images have been produced, the following reconstructionsand reformations are performed on selected images:

-   -   The images from the STIR sequence are assembled into a volume        and edited to create a 3-dimensional model of the brachial        plexus on the affected side(s). This model can be displayed in        any plane.    -   The images from the time of flight angiogram are assembled into        a volume and edited to create a 3-dimensional model of the        arteries on the affected side(s). This model can be displayed in        any plane.    -   The images from the optional time of flight venogram are        assembled into a volume and edited to create a 3-dimensional        model of the veins on the affected side(s). This model can be        displayed in any plane.

In patients with prior surgery for decompression of the thoracic outlet,the following optional sequences can be performed:

-   -   Axial gradient echo or fast spin echo T1 weighted sequence,        prescribed to cover the surgical bed on the affected side(s).    -   Sagittal gradient echo or fast spin echo T1 weighted sequence,        prescribed to cover the surgical bed on the affected side(s).

This process may be described in further detail as follows:

The patient is placed in supine position in the MRI scanner, with botharms in neutral position, by the side of the body. A neurovascular coilor similar coil that covers the upper chest, neck and supraclavicularfossa region on each side is used. The following sequences are thenperformed:

-   -   1. 3D localizer sequence, using gradient recalled technique.    -   2. Oblique coronal STIR (Short Tau Inversion Recovery) sequence,        oriented parallel to the C4/5 through C7IT1 neural foramina as        seen on sagittal images of the localizer sequence. Slices are 3        mm thick, with 0 mm interstice gap, and are prescribed from the        neural foramina posteriorly to the level of the anterior scalene        muscles anteriorly on the affected side(s).    -   3. Sagittal gradient echo T1 spin-echo T1 or fast spin echo        T2-weighted sequence, with slice thickness of 4 mm, interslice        gap of 0 mm, prescribed from the coracoid process on the left to        the coracoid process on the right.    -   4. Axial gradient echo T1, spin-echo T1, or fast spin echo        T2-weighted sequence, with slice thickness of 4 mm, interslice        gap of 0 mm, prescribed from the middle of the C4 body        superiorly to the mid-portion of the aortic arch caudally.

The patient is then removed from the scanner, placed back in the scannerwith both arms in hyperabduction and external rotation (approximately135 degrees of abduction), and a torso PA coil is placed under thepatient's back and over the patient's neck and chest to cover the upperchest, neck and supraclavicular fossa region on each side. Anintravenous line is placed in the patient's antecubital or hand vein atthis point in the study. The intravenous line is connected to a standardMRI power injector. The injector is pre-loaded with one syringe ofnormal saline, and one syringe containing a mixture of 30 cc ofgadolinium contrast material and 30 cc of normal saline. The followingsequences are then performed:

-   -   5. 3D localizer sequence, using gradient recalled technique.    -   6. Sagittal gradient echo T1 spin-echo T1 or fast spin echo        T2-weighted sequence, with slice thickness of 4 mm, interslice        gap of 0 mm, prescribed from the coracoid process on the left to        the coracoid process on the right.    -   7. Optional axial gradient echo T1, spin-echo T1 or fast spin        echo T2-weighted sequence, with slice thickness of 4 mm,        interslice gap of 0 mm, prescribed from the middle of the C6        body superiorly to the mid-portion of the aortic arch caudally.    -   8. Sagittal phase contrast angiogram, prescribed to cover the        carotid and vertebral arteries in the neck.    -   9. Gradient recalled “black blood” sequence for timing of        contrast injection. 2 cc of the solution containing 50%        gadolinium contrast material and 50% normal saline is injected        into the pre-existing intravenous line, starting at the same        time as the sequence is initiated, and 30 axial images are        obtained at the level of the carotid bifurcation, as determined        by the preceding phase contrast sequence, at the rate of one        image per second. These images are then evaluated for signal        intensity using the ‘functool’ function of a GE Medical Systems        MRI scanner console (or similar function available on all        commercial scanners). A region of interest is placed over the        carotid artery on these axial images, and the signal intensity        over time is plotted, starting at time=0 seconds. The time from        injection to peak signal intensity is determined and noted.    -   10. Magnetic resonance angiogram, oriented in the coronal plane,        prescribed to cover both carotid and vertebral arteries as        determined by the preceding phase contrast sequence (sequence        8). This sequence serves as a ‘mask’ for the next sequence, to        allow reduction of artifact and reduction of background noise.    -   11. Contrast-enhanced magnetic resonance angiogram, oriented in        the coronal plane, prescribed to cover both carotid and        vertebral arteries as determined by the preceding phase contrast        sequence (sequence 8). This sequence is initiated after the        injection of the remainder of the 50% gadolinium contrast/50%        saline solution pre-loaded into the power injector, utilizing        the delay calculated in sequence 9, plus one second. Thus, the        injection is initiated, the calculated delay is observed, and        the sequence is initiated immediately after the delay elapses.        This sequence produces source images for the magnetic resonance        anglogram.    -   12. If desired, contrast-enhanced magnetic resonance venogram,        oriented in the coronal plane, prescribed to cover both carotid        and vertebral arteries as determined by the preceding phase        contrast sequence. This sequence is an exact duplicate of the        immediately previous sequence, (sequence 11), and is initiated        immediately following the completion thereof. This sequence        produces images of the arteries and veins of the upper chest,        neck and upper extremities, which are source images for any        desired magnetic resonance venogram.    -   13. Single shot fast spin echo sequence, oriented in the coronal        plane, 10 mm slice thickness, single slice. This sequence is        used to determine the presence or absence of fluid or edema in        the soft tissues of the upper chest wall and supraclavicular        fossae.

In patients with prior surgery for decompression of the thoracic outlet,the following sequences are then performed:

-   -   14. Axial gradient echo or fast spin echo T1-weighted sequence,        with chemical fat suppression, slice thickness of 4 mm, and        interslice gap of 0 mm. The slices are prescribed from the        middle of the C6 body superiorly to the mid-portion of the        aortic arch caudally.    -   15. Sagittal gradient echo or fast spin echo T1-weighted        sequence, with chemical fat suppression, slice thickness of 4        mm, and interslice gap of 0 mm. The slices are prescribed from        the midline of the spinal canal to the coracoid process on the        post-surgical side(s).

After the above images have been produced, the following reconstructionsand reformations are performed on selected images:

-   -   16. Each image from the oblique coronal STIR sequence is        reviewed for the presence of brachial plexus components on the        affected side(s). All images that contain these brachial plexus        components are loaded into the Interactive Vascular        Imaging (IVI) software program on the GE Medical Systems MRI        scanner console (or similar function available on all commercial        scanners), and the surrounding tissues are electronically        removed in all planes, using the ‘Modify Model-ThresholdNOI’        function, leaving only the brachial plexus components on the        affected side(s). One 3-dimensional model is constructed for        each brachial plexus, including all components of the brachial        plexus from the level of the neural foramina medially through        the level of the retropectoralis space laterally on the affected        side(s). Each 3-dimensional model is then rotated in the        horizontal and vertical planes, using the ‘Display Modes-Set        Batch/Movie Loop’ function. Thus, two models of each brachial        plexus are constructed and saved for review.    -   17. Each image in sequence 10 is digitally subtracted from the        corresponding image in sequence 11, producing a new set of        images which represent source images for the arteriogram. These        images are loaded into the Interactive Vascular Imaging (IVI)        software program on the GE Medical Systems MRI scanner console        (or similar function available on all commercial scanners), and        the common carotid arteries, subclavian arteries, axillary        arteries and brachial arteries on each side are identified. One        projection image is constructed for the entire arterial tree,        using a Maximal Intensity Projection (MIP) technique. The        surrounding soft tissues are then electronically removed in all        planes, using the ‘Modify Model-Threshold/VOI’ function, leaving        only the major arteries on the affected side(s). A separate        3-dimensional model is then created for each arterial tree,        including the common carotid artery, subclavian artery, axillary        artery and brachial artery on the affected side(s) The        3-dimensional model created on each side is then rotated in the        vertical plane, using the ‘Display Modes-Set Batch/Movie Loop’        function.    -   18. Optionally, each image in sequence 10 is digitally        subtracted from the corresponding image in sequence 12,        producing a new set of images which represent source images for        the venogram. These images are loaded into the Interactive        Vascular Imaging (IVI) software program on the GE Medical        Systems MRI scanner console (or similar function available on        all commercial scanners), and the common carotid arteries,        subclavian arteries, axillary arteries, brachial arteries,        internal jugular veins, subclavian veins, axillary veins and        brachial veins on each side are identified. One projection image        is constructed for the entire arterial and venous tree, using a        Maximal Intensity Projection (MIP) technique. The surrounding        soft tissues are then electronically removed in all planes,        using the ‘Modify Model-Threshold/VOI’ function, leaving only        the major arteries and veins on the affected side (s). A        separate 3-dimensional model is then created for each combined        arterial and venous tree, including the common carotid artery,        subclavian artery, axillary artery, brachial artery, internal        jugular vein, subclavian vein, axillary vein and brachial vein        intact on the affected side(s). The 3-dimensional model created        on each side is then rotated in the vertical plane, using the        ‘Display Modes-Set Batch/Movie Loop’ function.

The complete set of 700-1,000 images is reviewed by a radiologist on aworkstation. The anatomic and pathologic points of interest to bereviewed and reported are listed below.

In each case, the skilled radiologist will understand that theinspection will reveal the presence or absence of certain features andbe able to identify those features that are associated with TOS. In someinstances, as in the evaluation of the scalene muscles and certain othermuscles of the right and left thoracic outlet, there appears no formalradiology literature on the appearance of these images, but surgeryliterature is available describing anatomic and pathologic changes inthe areas of concern, and the skilled radiologist will be able tointerpret these images on the basis of experience and knowledge of thisliterature.

-   -   Cervical spine disease        -   Degenerative disc disease        -   Degenerative joint disease        -   Central canal or neural foraminal stenosis        -   Integrity of spinal cord    -   Neck soft tissues        -   Lymphadenopathy        -   Soft tissue mass or cyst in neck, superior mediastinum, lung            apices or supraclavicular fossae    -   Brachial plexus and other neural structures        -   Branching pattern, caliber and signal intensity of brachial            plexus        -   Nerve root avulsion or pseudomeningocoele        -   Size and symmetry of stellate ganglia    -   Metrics of cervicothoracic junction        -   Superior thoracic aperture: measured from the posterior            border of the superior aspect of the manubrium to the            anterior cortex of the vertebral column, in the horizontal            plane, as seen on the midline sagittal image            -   Measured in both arms neutral and                hyperabduction-external rotation positions        -   First rib angle: measured relative to the horizontal, as            seen on the sagittal image demonstrating the longest segment            of first rib            -   Measured in both arms neutral and                hyperabduction-external rotation positions        -   C7 vertebral anatomy            -   Bony tubercles of body            -   Bony bars, extending to transverse processes and forming                pseudo-transverse foramina            -   Enlarged transverse processes            -   Cervical ribs    -   Right thoracic outlet        -   Scalene muscles            -   Size            -   Origins            -   Insertions            -   Interdigitating muscle bands            -   Scalene minimus muscles            -   Fibrous bands            -   Levator costae muscles            -   Slings        -   Scalene triangle-arms neutral            -   Apex            -   Base        -   Brachial plexus            -   Course relative to scalene muscles, scalene triangle and                anomalies of structures in “Right thoracic outlet,                Scalene muscles” listed above.        -   Other muscles            -   Subclavius                -   Size                -   Subclavius posticus variant            -   Pectoralis minor            -   Axillary arch        -   Anatomic tunnels-hyperabduction external rotation            -   Scalene Triangle            -   Costoclavicular interval            -   Subclavius-Serratus space            -   Retropectoralis space    -   Left thoracic outlet        -   Scalene muscles            -   Size            -   Origins            -   Insertions            -   Interdigitating muscle bands            -   Scalene minimus muscles            -   Fibrous bands            -   Levator costae muscles            -   Slings    -   Scalene triangle-arms neutral        -   Apex        -   Base    -   Brachial plexus        -   Course relative to scalene muscles, scalene triangle and            anomalies of structures in “Right thoracic outlet, Scalene            muscles” listed above.    -   Other muscles        -   Subclavius            -   Size            -   Subclavius posticus variant        -   Pectoralis minor        -   Axillary arch    -   Anatomic tunnels-hyperabduction external rotation        -   Scalene Triangle        -   Costoclavicular interval        -   Subclavius-Serratus space        -   Retropectoralis space    -   MR Angiogram        -   Aortic arch branching pattern        -   Great vessels and other major branches            -   Common carotid arteries            -   Vertebral arteries            -   Internal mammary arteries            -   Subclavian, axillary and brachial arteries as they pass                through anatomic tunnels            -   Dorsal scapular arteries and transverse arteries        -   Evaluate vessels for            -   Extrinsic compression            -   Intrinsic stenosis, or vascular disease            -   Post-stenotic dilatation            -   Anomalous course or vessel    -   MR Venogram        -   Neutral position        -   Subclavian and axillary veins        -   Left brachiocephalic vein            -   Compression in superior mediastinum        -   Internal and external jugular veins, and cephalic veins    -    Hyperabduction external rotation        -   Subclavian and axillary veins        -   Left brachiocephalic vein            -   Compression in superior mediastinum        -   Internal and external jugular veins, and cephalic veins    -    Evaluate vessels for        -   Extrinsic compression        -   Thrombus        -   Slowing of flow            -   Suggested by increased luminal signal intensity            -   Change in caliber between neutral and hyperabduction                external rotation            -   Presence of gadolinium contrast in veins    -    Lymphatics        -   Thoracic duct        -   Supraclavicular lymphatics        -   Edema of supraclavicular fossae or chest wall

1. (canceled)
 2. A method to evaluate a human subject for the presenceor absence of thoracic outlet syndrome (TOS) which method comprises:accessing a first three-dimensional model of a brachial plexus on anaffected side(s), the first three-dimensional model created based on afirst set of magnetic resonance imaging (MRI) slices obtained in each ofthree planes, in the absence of a contrast agent, with the subject in asupine position with both arms in a neutral position by a side of thebody, wherein obtaining the first set of MRI slices is configured tocomprise: obtaining a gradient echo T1, spin echo T1, or fast spin echoT2-weighted sequence that comprises sagittal slices that cover thescalene triangle, costoclavicular space, and retropectoralis space on anaffected side(s), obtaining a gradient echo T1, spin echo T1, or fastspin echo T2-weighted sequence that comprises axial slices that coverthe mid and lower cervical spine and lower neck, and the brachialplexus, supraclavicular space, superior mediastinum and lung apex on theaffected side(s), and obtaining a Short Tau Inversion Recovery (STIR)sequence that comprises slices that cover the volume of the brachialplexus on the affected side(s); accessing a second set of MRI slicesobtained in one or more planes, in the absence of the contrast agent,with the subject in a supine position with both arms placed in abductionand external rotation, by imaging the upper chest and neck, and thesupraclavicular fossa region on the affected side(s), wherein the secondset of MRI slices is configured to be obtained by a gradient echo T1,spin echo T1, or fast spin echo T2-weighted sequence that comprisessagittal slices that cover the scalene triangle costoclavicular spaceand retropectoralis space on the affected side(s); accessing a secondthree-dimensional model of arteries on the affected side(s), the secondthree-dimensional model created based on a plurality of slices from acontrast-enhanced magnetic resonance angiogram (MRA), wherein theplurality of MRA slices images the subclavian and axillary arteries onboth sides of the subject, wherein the plurality of MRA slices areconfigured to be obtained by administering a diluted contrast agentcomprising 50% gadolinium into a vein on a first side of the subjectsuch that the contrast agent enters arteries on both sides of thesubject and veins on both sides of the subject and obtaining acontrast-enhanced MRA, which images, in the subject, the contrast agent;and accessing a third three-dimensional model of the veins on theaffected side(s), the third three-dimensional model created based on aplurality of slices from a magnetic resonance venogram (MRV), whereinthe plurality of MRV slices images the subclavian, axillary, andbrachiocephalic veins on both sides of the subject, wherein theplurality of MRV slices are configured to be obtained by administeringthe diluted contrast agent comprising 50% gadolinium into the vein onthe first side of the subject such that the contrast agent entersarteries on both sides of the subject and veins on both sides of thesubject and obtaining the MRV, which images, in the subject, thecontrast agent; determining, based on the MRI slices, the presence ofabsence of stenosis; determining, based on the MRA, the presence ordegree of stenosis, external compression, or aneurysm, if any, in eachof the subclavian and the axillary arteries by assessing vascularcontrast enhancement, on both sides of the subject, determining, basedon the MRV, the presence or degree of stenosis or external compressionin each of the subclavian, axillary, and brachiocephalic veins on bothsides of the subject by assessing vascular contrast enhancement, on bothsides of the subject; and determining the presence or absence of TOSbased on the MRI slices, the MRA and the MRV, and an evaluation of thefirst three-dimensional model, the second three-dimensional model, andthe third three-dimensional model.
 3. The method of claim 2, wherein thecontrast agent further comprises 50% normal saline.
 4. The method ofclaim 2, wherein the arteries comprise upper extremity arteries andwherein the veins comprise upper extremity veins.
 5. The method of claim2, wherein the obtaining the first set of MRI slices is furtherconfigured to comprise a surface coil is disposed over the subject tocover the upper chest and neck and the supraclavicular fossa region onthe affected sides.
 6. A method to evaluate a human subject for thepresence or absence of thoracic outlet syndrome (TOS) which methodcomprises: accessing a first three-dimensional model of a brachialplexus on an affected side(s), the first three-dimensional model createdbased on a first set of magnetic resonance imaging (MRI) slices obtainedin each of three planes, in the absence of a contrast agent, with thesubject in a supine position with both arms in a neutral position by aside of the body, wherein obtaining the first set of MRI slices isconfigured to comprise: obtaining a gradient echo, spin echo, or fastspin echo sequence that comprises sagittal slices that cover thethoracic outlet on an affected side(s), obtaining a gradient echo, spinecho, or fast spin echo sequence that comprises axial slices that coverthe mid and lower cervical spine and lower neck, and the brachialplexus, supraclavicular space, superior mediastinum and lung apex on theaffected side(s), and obtaining a Short Tau Inversion Recovery (STIR)sequence that comprises slices that cover the volume of the brachialplexus on the affected side(s); accessing a second set of MRI slicesobtained in one or more planes, in the absence of the contrast agent,with the subject in a supine position with both arms in abduction andexternal rotation, by imaging the upper chest and neck, and thesupraclavicular fossa region on the affected side(s), wherein the secondset of MRI slices is configured to be obtained by a gradient echo, spinecho, or fast spin echo sequence that comprises sagittal slices thatcover the thoracic outlet on the affected side(s); accessing a secondthree-dimensional model of arteries on the affected side(s), the secondthree-dimensional model created based on a plurality of slices from acontrast-enhanced magnetic resonance angiogram (MRA), wherein theplurality of MRA slices images the subclavian and axillary arteries onboth sides of the subject, wherein the plurality of MRA slices areconfigured to be obtained by administering a diluted contrast agentcomprising 50% gadolinium into a vein on a first side of the subjectsuch that the contrast agent enters arteries on both sides of thesubject and veins on both sides of the subject and obtaining acontrast-enhanced MRA, which images, in the subject, the contrast agent;and accessing a third three-dimensional model of the veins on theaffected side(s), the third three-dimensional model created based on aplurality of slices from a magnetic resonance venogram (MRV), whereinthe plurality of MRV slices images the subclavian, axillary, andbrachiocephalic veins on both sides of the subject, wherein theplurality of MRV slices are configured to be obtained by administeringthe diluted contrast agent comprising 50% gadolinium into the vein onthe first side of the subject such that the contrast agent entersarteries on both sides of the subject and veins on both sides of thesubject and obtaining the MRV, which images, in the subject, thecontrast agent; determining, based on the MRI slices, the presence ofabsence of stenosis; determining, based on the MRA, the presence ordegree of stenosis, external compression, or aneurysm, if any, in eachof the subclavian and the axillary arteries by assessing vascularcontrast enhancement, on both sides of the subject, determining, basedon the MRV, the presence or degree of stenosis or external compressionin each of the subclavian, axillary, and brachiocephalic veins on bothsides of the subject by assessing vascular contrast enhancement, on bothsides of the subject; and determining the presence or absence of TOSbased on the MRI slices, the MRA and the MRV, and an evaluation of thefirst three-dimensional model, the second three-dimensional model, andthe third three-dimensional model.
 7. The method of claim 6, wherein thecontrast agent further comprises 50% normal saline.
 8. The method ofclaim 6, wherein the arteries comprise upper extremity arteries andwherein the veins comprise upper extremity veins.
 9. The method of claim6, wherein the obtaining the first set of MRI slices is furtherconfigured to comprise a surface coil is disposed over the subject tocover the upper chest and neck and the supraclavicular fossa region onthe affected sides.
 10. The method of claim 6, wherein the thoracicoutlet comprises a scalene triangle, a costoclavicular space, and arectropectoralis space.